Community Health Workers are vital to Arizona’s healthcare equity, workforce and communities

The Centers for Disease Control and Prevention’s (CDC) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) defines a community health worker (CHW) as “a frontline public health worker who is a trusted member or has a particularly good understanding of the community served. A CHW serves as a liaison between health and social services and the community to facilitate access to services and to improve the quality and cultural competence of service delivery.”

In Arizona’s rural communities they are frequently called community health workers. In tribal nations and within the Indian Health Service, they are often known as community health representatives (CHRs). In Southern Arizona communities, they may be called promotoras or promotores.

No matter what title we use for these frontline public health workers, they have been a beloved and integral part of Arizona’s, as well as tribal nations’, communities’ healthcare systems for decades. CHW/CHR’s are often beloved superstars because they facilitate connections between community, healthcare and social service organizations with personal knowledge and background of the communities they serve and often can communicate with patients and community members in their native languages.

How to pay these superstars, however, has often presented a budgeting challenge. CHW certification is a key part of achieving payment for CHW services.

A success story published on the CDC’s Prevention Research Centers website titled “University of Arizona Prevention Research Center (AzPRC) and Public Health Partners Achieve State Certification Path for Community Health Workers,” describes the background of voluntary CHW certification in Arizona. The AzPRC led the development of partnerships with “the Arizona Department of Health Services (ADHS), the Arizona Community Health Workers Association (AzCHOW), and other CHW organizations to establish the Arizona CHW Workforce Coalition. This coalition then developed Arizona CHW core competencies and a scope of practice.” The Arizona CHW Workforce Coalition worked to educate legislators about CHWs and identify sustainable funding mechanisms as part of efforts to formalize voluntary CHW certification.

In 2018, the Arizona Legislature passed HB2324, and Governor Ducey signed it into law. HB2324 required the ADHS to establish qualifications, a scope of practice, and core competencies to certify CHWs. ADHS also established a voluntary certification program that outlined education and training program requirements and standards for CHW/CHR trainers. In November 2022, the ADHS published a Final Rule regarding the Voluntary Certification for Community Health Workers. This certification is required for CHW/CHR’s services to be eligible for Medicaid reimbursement. CHW certification pathways require combinations of education, training and CHW experience.

Arizona’s Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS), subsequently introduced a plan to enable healthcare and community service organizations to bill Medicaid for CHW services. Specifically, it includes dedicated codes for certified CHW/CHR services. For example, several billable service codes for certified CHW/CHR’s address education and training provided to an individual patient in 30-minute increments, as well for groups of two to four patients, and another for five to eight patients. CHW/CHRs may also provide services via telehealth. Answer A12 in the AHCCCS FAQ’s Community Health Worker/Community Health Representative PDF states that “CHW/CHR Medicaid covered services may be provided via telehealth so long as they align with the telehealth requirements outlined in the AHCCCS Medical Policy Manual 320-I.” The AHCCCS Medical Policy Manual 320-I PDF includes conditions and limitations for telehealth services including maintaining privacy and confidentiality, obtaining informed consent and more.

Arizona’s certified CHW’s scope of practice, roles and activities are detailed in Figure 1.

Figure 1 Excerpt from the Arizona Administrative Registrar that lists a certified CHW’s scope of practice, along with other roles and activities that a CHW may and may not participate in.

Kyle Sawyer, assistant director of public policy and strategic planning at AHCCCS, expounded on CHW/CHR’s during his presentation at the Arizona Telemedicine Program’s 2023 Arizona Telehealth Policy Summit last October.

“Getting that voluntary certification is really the first step into getting reimbursement from the state Medicaid agency, so we only reimburse for services provided by the voluntarily certified CHW/CHR’s,” he told attendees, adding that AHCCCS negotiated with the state and feds to have the CHW/CHR services reimbursed through Medicaid.

Sawyer said the real exciting news is that starting April 1, 2023, the CHW/CHR Medicaid reimbursement finally took effect.

“We really wanted to stand up this program as soon as possible. We saw the importance of these workers to our community. … as most of you know, a CHW is a frontline public health worker. They're trusted members of the community. They help people navigate the healthcare system and manage their chronic illnesses, maintain healthy lifestyles, etc.,” he said.

According to Sawyer, the numbers of Community Health Workers (CHWs) obtaining voluntary certification are on the rise.

Sawyer added that in 2024, organizations currently not registered with Medicaid who use CHW/CHR’s and promotores in their community settings will have the opportunity to register. This registration will enable them to reimburse and compensate these community workers. He also added that right now the state has three reimbursable service codes for CHW/CHR’s, but if clinics and organizations have ideas for additional codes, they should reach out to AHCCCS.

“We'll continue to evaluate any additional services that might fit in with the scope of services of a CHW/CHR,” he said. “We will also take any public feedback. If you find a different code that you feel fits into our scope of service, send it our way. We can get it to our coding teams to have it evaluated.”

The ongoing changes in budgeting and payment processes for CHW/CHR’s, as well as the certification requirement from AHCCCS, is further fueling statewide workforce discussions and development. Organizations such as AzCHOW are taking the lead in facilitating these discussions. They bring together CHW/CHRs across the state, fostering partnerships, collaborations, and contributing to the growth of certifications. The ability for AHCCCS-registered providers to bill Medicaid for some of the services certified CHW/CHRs provide is paving the way for these public health workforce superheroes to lift community economies and address healthcare equity and worker shortages.

A 2022 report from the Medicaid and CHIP Payment and Access Commission, discusses the effects of CHW programs stating that “There is a substantial body of research indicating that the use of CHWs can improve health outcomes and produce other positive effects. Although few studies focus specifically on CHW programs serving Medicaid beneficiaries, some have found evidence of improved outcomes or cost savings for Medicaid."

The Center for Health Equity Research (CHER) at Northern Arizona University, lauded the creation of the voluntary CHW certification last year, pointing out that the number of CHW/CHR workers in Arizona, estimated at more than 2,000 in November 2022, will grow because of the certification.

In a CHER report, CHER senior research coordinator Louisa O’Meara said “Voluntary CHW certification is critical to the sustainability of the CHW workforce, which for more than 50 years has relied on a patchwork of funding making it harder for CHWs and CHRs to operate at the top of their scope of practice. … We also know that voluntary certification of the CHW workforce is associated with better wages, which helps recruit and retain CHWs, lifting the whole workforce up.”

The result is a growing number of trainings offered to CHW/CHR’s throughout the state. AzCHOW has a training program approval process, and currently lists eight approved training programs including Central Arizona Community College. AzCHOW also has a training approval guidelines to help programs develop volunteer certifications that meet state approval. Indian Health Service also offers an online CHR training program.

In October 2023, Pima Community College, in partnership with El Rio Community Health Center, launched its first Community Health Workers Training Program class as part of the college’s Workforce Development and Lifelong Learning offerings.